Provider Demographics
NPI:1720366255
Name:FALLON, MITCHELL THOMAS (PAC)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:THOMAS
Last Name:FALLON
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3760 CONVOY ST
Mailing Address - Street 2:114
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-3742
Mailing Address - Country:US
Mailing Address - Phone:858-715-8444
Mailing Address - Fax:
Practice Address - Street 1:3760 CONVOY ST
Practice Address - Street 2:114
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-3742
Practice Address - Country:US
Practice Address - Phone:858-715-8444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-02
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21619363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant